It is the policy of Me and My Nanna, LLC Agency to provide employment opportunities without regard to race, color, religion, sex, national origin, age, handicap, or veteran status.

APPLICATION FOR EMPLOYMENT

Date *

Last Name *

First Name *

Middle Initial *

Street Address *

City *

State

Zip *

Telephone *

Last 4 of Social Security

Email *

Position Applying for *

How did you hear about this opening?

Have you ever been employed by the company?

Yes

No

If yes, when?

Where?

Position?

When can you start?

Are you a U.S. citizen or otherwise authorized to work in the U.S. on an unrestricted basis?

Yes

No

Do you have a valid driver’s license?

Yes

No

License No.

State

Exp Date

Which type of employment are you looking for?

Full-time

Part-time

Visits

PRN

Have you ever been convicted of a felony? (This will not necessarily affect your application)

Yes

No

If yes, please describe conditions

EDUCATION

HIGHSCHOOL

School Name and Location

Year

Degree

Yes

No

COLLEGE

School Name and Location

Year

Degree

Yes

No

POST-COLLEGE

School Name and Location

Year

Degree

Yes

No

OTHER TRAINING

School Name and Location

Year

Degree

Yes

No

In addition to your work history, are there other skills, qualifications, or experience that we should consider?

EMPLOYMENT HISTORY

Present or Most Recent Employer

Company Name

Address

Telephone

Date Started

Starting Wage

Starting Position

Date Ended

Ending Wage

Ending Position

May we contact?

Yes

No

Responsibilities

Reason for leaving

Company Name

Address

Telephone

Date Started

Starting Wage

Starting Position

Date Ended

Ending Wage

Ending Position

May we contact?

Yes

No

Responsibilities

Reason for leaving

Company Name

Address

Telephone

Date Started

Starting Wage

Starting Position

Date Ended

Ending Wage

Ending Position

May we contact?

Yes

No

Responsibilities

Reason for leaving

Have you ever been suspended, placed on probation, asked to resign, discharged or terminated?

Yes

No

If yes, please explain

* I certify that the facts set forth in this application for employment are true and complete to the best of my knowledge. I understand that if I am employed, false statements on this application shall be considered sufficient cause for dismissal. This company is hereby authorized to make any investigations of my prior educational and employment history

* I understand that employment at this company is “at will”, which means that either I or this company can terminate the employment relationship at any time, with or without prior notice, and for any reason not prohibited by statue. All employment is continued on that basis. I understand that no supervisor, manager, or executive of this company, other than the president, has any authority to alter the foregoing.